Debabrata Mukherjee, MD, MS, FACC

As ice and snow loosen their grip on most of the country, I hope we are ready to shake off the winter blues and enjoy spring. In line with the season for rejuvenation, renewal, resurrection, and regrowth, this particular issue of 

 discusses many important articles and viewpoints that I hope will rejuvenate our minds.

Dr Saurav Chatterjee discusses a U-shaped association of body mass index (BMI) with all-cause mortality among patients with type 2 diabetes and opines that there still remains a need to reevaluate the long-term effects of weight loss on mortality risk among patients with type 2 diabetes. Meanwhile, it would appear prudent that all persons with diabetes mellitus, regardless of weight status, be treated aggressively to mitigate health risks.

Dr Leslie Campbell reviews the association between the use of beta-blockers and outcomes in heart failure patients with preserved ejection fraction, and muses that evidence-based therapies for heart failure patients with preserved ejection fraction are shallow in number compared with the evidence for therapies in heart failure patients with reduced ejection fraction. Although there may be some common risk factors for these syndromes, there are also important differences in risk predictors. She further states that the available data imply that different treatment strategies may be needed for heart failure patients with preserved ejection fraction versus those with reduced ejection fraction

 Dr Nezar Falluji discusses the best strategy for patients with moderate intermittent claudication and suggests that an early revascularization may be a better strategy in these patients. He points out the importance of incorporating quality of life, patient-centered, qualitative end points in assessing stable symptomatic medical conditions, where the patients’ perception of treatment effectiveness is as important as more objective measurable quantitative end points.

Dr Maryna Popp Switzer looks at the effects of fish consumption and acute coronary syndromes. She reports that fish consumption is beneficial, with multiple positive effects on cardiovascular health, including primary prevention of acute coronary syndromes. She further states that both men and women should aim for at least 2 servings of baked or broiled fish per week as part of their comprehensive health plan.

Dr Alison Bailey examines sexual activity and counseling in the first month after acute myocardial infarction among younger adults, and suggests that methods to improve the patient-physician discussion about sexual activity after heart attacks should be explored and current guidelines incorporated into sexual activity recommendations for our younger patients with heart attacks.

For our Clinical Forum section, Drs Eric Bates, Pareena Bilkoo, and Hitinder Gurm discuss the hot-button issue of multivessel versus culprit-vessel-only angioplasty in patients with acute myocardial infarction. I am sure you will enjoy their insightful comments. Overall, it would appear reasonable that physicians evaluate both clinical data and lesion complexity to determine the optimal strategy for angioplasty in a patient with multivessel coronary artery disease and myocardial infarction.

Finally, the insightful compilation of studies presented at Obesity Week by our excellent managing editor, Ms. Jackie Syrop should keep you updated on the latest happenings in the obesity and diabetes field. She also discusses several key items in the news, namely aspirin overuse for primary prevention, FDA approval of Savaysa, and the FDA’s approval of the Enroute Transcarotid Neuroprotection System for carotid stenting.

I hope that you will find these commentaries to be valuable and enjoyable. I encourage you to share your insights, thoughts, and personal experiences on the topics touched upon in this issue. On a broader level, I would love to hear feedback on how we can make this journal even better. My goal continues to be to make you look forward to every print and online issue of 

Articles

Cardiology Review editor-in-chief Debabrata Mukherjee, MD, reviews the contents of this month's issue.

Shake Off the Winter Blues with Cardiology Review

I hope everyone had an enjoyable holiday season! I also want to wish everyone a wonderful New Year. With the holidays over, it is back to work for most of us, and this month’s 

should help us in getting caught up with the latest news and advances in cardiology. This issue of 

discusses many important articles and viewpoints that I am sure you will find quite useful.

Dr Glenn Levine delves into the efficacy of drug-eluting versus bare-metal stents in saphenous vein bypass graft percutaneous coronary intervention, and opines that the propensity of data favors the use of drug-eluting stents in patients undergoing saphenous vein bypass graft percu&shy;taneous coronary intervention. He further states that additional data will likely be available at the end of 2016 when results of the VA Cooperative Study Drug-Eluting Stents vs Bare Metal Stents in Saphenous Vein graft Angioplasty (DIVA) study become available.

Drs Kazuhiko Kido and Tracy Macaulay discuss increased mortality associated with digoxin in atrial fibrillation patients, and state that it remains a matter of controversy whether use of digoxin should be stopped completely based only on study results from observational studies.

However, at the least, the use of digoxin should be strictly evaluated and its initiation selected with care in patients with atrial fibrillation. Until further evaluation, digoxin should be reserved for patients who have symptomatic hypotension and/ or heart failure with reduced ejection fraction, when other rate-control agents cannot be safely initiated.

Dr Harry Davis examines the benefit of a combined healthy diet and lifestyle on the incidence of myocardial infarction. He reflects that there is growing evidence that supports the reduction of morbidity and mortality through adoption of healthy dietary and lifestyle patterns. He suggests that physicians must pursue the development of patient behavior that increases the likelihood that patients will make healthier choices. However, this may well be an enormous challenge, and he paraphrases an old saying from many centuries ago: “The gate is narrow and the road is hard that leads to life, and there are few who find it.”

Dr Jimena Blandon reviews the role of angiotensin receptor blockers in heart failure patients with preserved ejection fraction and worsening renal function. She opines that randomized con&shy;trolled trials that assess the relationship between worsening renal function and hard cardiovascular events (death, hospitalizations, worsening heart failure) in patients with heart failure with preserved ejection fraction treated with renin-angiotensin inhibitors are much needed before it will be possible to conclude that such agents are not effective or are undesirable in treating this group of patients. Dr Mushabbar Syed reviews diffuse myocardial fibrosis and its association with diastolic dysfunction in heart failure with preserved ejection fraction, and emphasizes that abnormal passive ventricular stiffness is likely the major contributor to diastolic dysfunction from diffuse myocardial fibrosis.

Dr Saurav Chatterjee examines varenicline with and without nicotine replacement therapy for smoking cessation and concludes that while varenicline, in combination with nicotine replace&shy;ment therapy, was more effective than varenicline alone at achieving tobacco abstinence at 12 weeks and at 6 months, additional studies are needed to assess the long-term efficacy and safety of the combination.

For our Diabetes section, Dr Aparna Bhagavat reviews short- and long-term effects of intensive diabetes and blood pressure control. She suggests that that there is a significant benefit in sustained and continued blood glucose and blood pressure control on microvascular and event rate and overall mortality among patients with diabetes.

Finally, the insightful compilation of top stories and meeting highlights from the American Heart Association by our excellent managing editor, Ms. Jackie Syrop, should keep you updated on the latest happenings in this field. She discusses several key items in the news, namely the Dual Antiplatelet Therapy Study; IMPROVE-IT, the Vytorin (Ezetimibe/Simvastatin) versus Simvas&shy;tatin trial; the BASKET-PROVE II study comparing safety and efficacy of 3 new types of coronary stents; and the EVOLVE II clinical trial to assess the SYNERGY stent system for the treatment of atherosclerotic lesion(s).

I hope that you will find these commentaries to be valuable and enjoyable. I encourage you to share your insights, thoughts, and personal experiences on the topics touched upon in this issue. On a broader level, I would love to hear feedback on how we can make this journal even better. My goal continues to be to make you look forward to every issue of 

This issue of Cardiology Review discusses many important articles and viewpoints that I am sure you will find quite useful. 

Best Wishes for a Wonderful New Year!

We are finally ready to move on from the scorching summer days to beautiful fall splendor in many parts of our country. Many of us are also looking forward to the football season, and some of us are hoping that our home teams will do better this year. On a more serious note, this issue of 

 provides discussion and viewpoints on many important articles, which I am sure you will find quite useful.

Drs Niki Katsiki and Dimitri P. Mikhailidis review US trends in the last 20 years of diabetes-related complications and report that diabetes-related morbidity and mortality has been substantially reduced during the last 2 decades. However, there is a need for further improvements in prevention, early diagnosis, and effective treatment of diabetes mellitus and diabetic complications, especially in light of the rapidly increasing prevalence of obesity and diabetes mellitus worldwide.

Drs Steven Stevens and Kalyanam Shivkumar discuss leadless self-contained pacemakers in humans and opine that the LEADLESS trial demonstrated an innovative and sweeping advance in cardiac pacing technology. The fate of this innovation as a true contender in the pacing world will depend on whether it can compile reasonable safety record, one which will need to exceed our expectations of traditional pacing with a lead and pulse generator.

Dr Thomas Whayne looks at alternative medicines and supplements for the primary prevention of cardiovascular disease and cancer, and warns that clinical guidelines developed by the US Preventive Services Task Force cast much doubt on alternative medications and dietary supplements consisting of vitamins and/or minerals. Nevertheless, the clinical reality is that the use of various dietary supplements by patients will probably continue. He suggests that each patient will have to be assessed individually and made a partner in any decision on supplementation, based on the available evidence.

Dr Saurav Chatterjee reviews optimal duration of dual antiplatelet therapy after drug-eluting stent implantation. Although the risks of late stent thrombosis with drug-eluting stents, especially after cessation of dual antiplatelet therapy, are well known, the optimal duration of dual antiplatelet therapy following percutaneous coronary intervention with drug-eluting stents remains unclear. Emerging data suggest that optimal duration of dual antiplatelet therapy after newer-generation drug-eluting stents may be significantly shorter, which is being tested in prospective studies.

Dr Glenn Levine discusses the impact of coronary collateral circulation on outcomes in patients with acute coronary syndromes, and states that it is intuitive that the presence of coronary collateral circulation should be cardioprotective and beneficial. The presence of collateral vessels subtending the area of jeopardized myocardium should provide at least some blood flow, which may prevent irreversible myonecrosis, or at least delay or mitigate myonecrosis until a time when an occlusion may become at least partially patent again, either by administered anticoagulant or thrombolytic therapy, through mechanical intervention, or spontaneously. This should lead to avoidance of MI or a smaller degree of myonecrosis, greater preservation of left ventricular function, and improved prognosis. However, he points out, despite these potential benefits, it is unclear how this information can be used to improve outcome and prognosis in patients with acute coronary syndromes.

Dr Alison Bailey discusses live counseling versus website-based lifestyle/medication intervention to reduce heart disease risk, and thinks that that there are innovative strategies to improve cardiovascular health variables beyond personally delivered counseling. She further affirms that we must continue to explore new options for motivating individuals to make sustainable change, and technology will surely play a role.

In our Clinical Forum section, Drs Hitinder Gurm, Mehdi Shishehbor, and Khaled M. Ziada have a lively discussion on the future role of renal denervation. It remains to be seen whether the SYMPLICITY HTN-3 hypertension trial was a death knell for this technology or if renal denervation can overcome the negative results with better-designed trials. I am sure you will enjoy the debate.

Also, our rundown of major studies presented at American Diabetes Association’s 74th Scientific Sessions should keep you updated on the latest happenings in this field. Managing editor Jackie Syrop discusses several of the most exciting, including combination diabetes drug therapy, the role of lifestyle and metformin in delaying diabetes onset, the concept of a “bionic pancreas,” and the cost-effectiveness of statins.

In this issue of Cardiology Review, we cover a wide variety of topics while saying goodbye to the summer of 2014.

Summer's Almost Gone, There's Much to Still Look Forward To

he hot summer days are upon us and in this issue of 

we cover several burning topics of interest to clinicians. Dr. Pareena Bilkoo discusses the safety and efficacy of drug-eluting stents (DESs) in women and opines that although drug-eluting stents have become the standard of care for coronary artery disease, prospective data on the safety and efficacy of DESs in women are lacking because women are underrepresented in stent trials, making up only a small proportion of study participants. Based on the analysis by Stefanini et al, Dr. Bilkoo reassures us that the results in women with DES are consistent with those for men and ap- pear equally effective. She does point out the need for additional pro- spective studies to assess the safety and efficacy of DESs in women.

	Dr. Leslie Campbell reviews and reassesses the role of digoxin in heart failure and concludes that rather than focus on a somewhat archaic medication that has little prospective evidence to support its widespread use, she would favor exploring new sensor and computer technologies to monitor high-risk patients at home to prevent readmissions. She further states that digoxin should be a “last DIG effort” in heart failure treatment.

	Dr. Nezar Falluji discusses the role of red blood cell transfusion in patients undergoing percutaneous coronary interventions. He concludes that available data highlight the need for randomized controlled trials to help delineate the appropriate use of blood trans- fusion in patients undergoing percutaneous coronary interventions. Blood transfusion is expensive and is associated with the risk of blood-borne infections and other adverse effects, and pending more definitive data, most experts and guidelines recommend a restrictive transfusion strategy taking into account the clinical assessment of the patient (rather than an absolute hemoglobin or hematocrit value) to guide the decision regarding blood transfusion.

	Dr. Harold Lazar examines mitral valve repair versus replacement for severe ischemic mitral regurgitation and reports that de- spite correction of mitral regurgitation, patients with ischemic mitral regurgitation still have a poor long-term prognosis. Mitral valve replacement is a more reliable technique to limit recurrent mitral regurgitation but does not improve survival or reverse adverse ventricular remodeling after 1 year. Furthermore, simple ring annuloplasty is not sufficient to alleviate mitral regurgitation when there are changes in both the annulus and the subchordal apparatus.

	Dr. Icilma Fergus reflects on whether anger predicts a higher likelihood of cardiovascular events and states that data suggest that within the 2 hours following an anger outburst there is a higher risk of heart attacks, ischemic and hemorrhagic stroke, as well as arrhythmia. She thinks that the meta-analysis by Motofsky et al is a helpful guide in characterizing additional risk categories when assessing pa- tients prone to cardiovascular events.

	Dr. Diana Fancher discusses a very hot topic: the validity of health care insurance exchanges that are mandated by the Affordable Care Act (ACA). She points out that considering that the intent of the ACA’s proponents was to increase access to health insurance by the nation’s uninsured, a successful argument against individual subsidies for the federally run exchanges would potentially have great impact on the concept of social justice. The very people the ACA was designed to assist would be left, once again, without the ability to pay for or access health care.

	In our diabetes section, Dr. Aparna Bhagavat addresses childhood obesity in the United States, and notes that the enormous burden of childhood obesity has its impact not only in adulthood but also leads to numerous health and psychosocial problems in childhood. She further reflects that it is primarily the responsibility of parents, teachers, and health care professionals to be role models for the younger generation with respect to healthy eating and physical activity. The key to solving this problem is to continue to promote education through research, publications, and public media. Finally, Jackie Syrop (our excellent managing editor), has put together a succinct summary of several key clinical trials presented at the American Society of Hypertension meeting and key news items, which I am sure you will find to be useful reading.

	I hope that you will find these commentaries to be valuable and enjoyable. I encourage you to share your insights, thoughts, and personal experiences on the topics touched upon in this issue. On a broader level, I would love to hear feedback on how we can make this journal even better. My goal continues to be to make you look forward to every issue of 

In this issue of Cardiology Review, we cover several burning topics of interest to clinicians.

Debabrata Mukherjee, MD, MS, FACC

Articles

Latest News